Meth has changed, and it’s sabotaging Oregon’s mental health system

Editor’s note: This is Part 1 of a two-part series about how — despite a windfall of new funding — the state has no plan to address the “new meth” that is overwhelming behavioral health providers and inflaming ongoing crises across the state. On Friday: The Lund Report will take a look at how the state’s siloed approach to behavioral health is undermining its response to the increasing problem of meth.

Every time Anthony Ware got out of prison, he noticed the meth in Portland tasted more like chemicals.

“My daily routine was like, wake up, eat a piece, let that kick in, and then smoke to keep my high,” he said of that time in his life.

It was the “good stuff,” cooked by local bikers, that got Ware hooked on meth nearly two decades ago, he said. Then the drug cartels started making it. By 2018, the drug reminded him of “paint fumes.”

The changes Ware witnessed were at the heart of an article published in The Atlantic magazine this past October. In it, journalist Sam Quinones contended that cartels’ new formula for making meth is driving people into the throes of psychosis and homelessness at a much higher rate. With this “new meth,” he wrote, “traffickers forged a new population of mentally ill Americans.”

The observation holds particular relevance for Oregon, which has the highest reported rate of meth use in the nation. And more than two dozen interviews by The Lund Report with those involved in Oregon’s behavioral health system reveal that at every level, it’s well known that meth has changed — and that it’s inflaming Oregon’s already blistering addiction, mental health and homelessness crises like never before.

At the state’s largest psychiatric facility, the Oregon State Hospital, the overcrowding that has dominated headlines for years is, employees say, driven by a flood of patients whose mental illness is intertwined with meth. This, in turn, is closing out other acutely ill patients who instead are warehoused at other Oregon hospitals, increasing costs and taxing staff.

But despite widespread awareness among insiders, there’s been little public recognition of the outsized role meth is playing in problems plaguing Oregon’s mental health system. There’s also no coordinated approach to address it.

Experts, advocates and local officials say that needs to change.

“We’re up against formidable challenges right now in Oregon,” said Dr. Todd Korthuis, the head of addiction medicine at Oregon Health & Science University. “Not only do we have increases in methamphetamine use, but we have rapidly spiking increases in the number of fentanyl overdoses. And it’s going to require an all-hands-on-deck approach to really tackle all of these issues at once — with multiple different approaches.”

A rise in meth use and related mental illness

In 2004, a sheriff’s deputy in Multnomah County came up with a public awareness campaign called Faces of Meth to highlight the drug’s corrosive impact.

Two years later, focus on the drug and its connection to psychotic behavior prompted Oregon lawmakers to adopt the country’s first ban on over-the-counter sales of ephedrine, the plant-based main ingredient for the small-scale local manufacturing then dominating the market. Congress soon followed suit.

Mexican cartels, however, promptly flooded the Oregon market, and began using a different method to make the drug, known as phenyl-2-propanone, or P2P. It was synthetic, cheaper and more potent.

It’s this P2P meth that Quinones, in The Atlantic, contended more frequently leads to mental illness. The link between meth and psychosis isn’t new, though studies validating the connection primarily focused on older iterations of the drug.

With symptoms like paranoia, delusions and hallucinations, it’s difficult for practitioners to differentiate between mental illnesses like schizophrenia and those that are meth induced. A common characteristic is for the afflicted person to believe someone or something is after them. At its worst, this can result in aggressive and even violent behavior.

Despite Oregon’s early attempts to combat meth, its reach has only worsened:

• In 2020, Oregon jumped from having the ninth highest rate of meth use in the country to the highest, according to the most recent National Survey on Drug Use and Health data.
• The volume of meth confiscated on Oregon highways saw a 75% increase between 2016 and 2020, according to drug trafficking reports.
• Meth-related emergency department visits in Oregon climbed about 20% in both urban and rural areas between 2018 and 2021, and last year, urban hospitals alone saw more than 16,000 meth-related emergency department visits, according to Oregon Association of Hospitals and Health Systems data.
• The number of those patients spending more than 24 hours in an emergency department bed doubled during that time.
• The price of meth has dropped to as little as $5 for a three-day high, while the potency has increased. Anecdotal reports suggest meth overtook heroin as the drug of choice among Portlanders experiencing homeless as early as 2007.
• In 2019, Portland’s only sobering center closed, with its operator, Central City Concern, citing an inability to safely sober the increasing number of people coming in who were behaving violently and erratically while under the influence of meth and similar drugs.
• Methamphetamine contributed to more deaths in Oregon than fentanyl and heroin in 2019, 2020 and 2021.

Michelle Guyton and fellow forensic psychologist Alexander Millkey of Northwest Forensic Institute, LLC in Portland evaluate criminal defendants’ ability to stand trial for courts around the state. And they’ve been busy — over the last decade, the number of people deemed unfit to proceed with their criminal defense in Oregon has nearly tripled, according to state data.

Guyton and Millkey told The Lund Report that nearly everyone they evaluate uses meth.

“Frankly,” Millkey said, “if you have somebody who’s not using meth, it’s a very refreshing palate cleanser.”

In recent years, they said they’ve seen an increase in the number of defendants experiencing meth-induced psychosis. It usually resolves within a couple of weeks, but for some, it can take months or even years — if it’s resolved at all — Millkey said.

Guyton said the line between meth-induced psychosis and traditional mental health disorders has become “increasingly grayer.”

“I agree with the Atlantic article that new meth is a different bird,” Millkey said. “I don’t know if I’m seeing meth induced psychosis that lasts longer. But I do know that I am seeing more meth induced psychosis.”

A recipe for severe illness

Most experts interviewed for this story emphasized the high rate of homelessness among the most acutely psychotic people who use meth.

Annual Point in Time surveys, which take a one-day snapshot of homelessness each January, show that between 2015 and 2022, homelessness counts more than tripled in central Oregon and went up by nearly 40% in Multnomah County.

For many unhoused people, living outside evokes a hypervigilant state marked by trauma and sleeplessness. Often, self-care doesn’t happen. When these factors combine with meth use, experts say, it can be a recipe for longer lasting and more severe psychotic events. This can be especially true for people who are genetically prone to developing mental health disorders.

But homelessness and meth use don’t result in psychosis for everyone.

Quinones’ article in The Atlantic featured Rachel Solotaroff, then the executive director of Central City Concern, Portland’s largest homeless services provider. He quoted her saying that the “degree of mental-health disturbance; the wave of psychosis; the profound, profound disorganization” among her patients who use meth was something she had “never seen before.” She also told Quinones, “If they’re not raging and agitated, they can be completely noncommunicative … I’ve never experienced something like this — where there’s no way in to that person.”

Earlier this year, Solotaroff told The Lund Report she was talking about the behavioral effects of meth use at their most extreme during that interview.

Many of her patients “use meth regularly, or use meth intermittently, and do not present with that kind of symptomology,” she said. “I never meant to convey that there is a population of folks for whom there is no hope or there is no opportunity for connection.”

Ware, who noticed changes in meth over 15 years of use, never became psychotic, though he did struggle with mental health issues.

He’s mixed race and felt neither his Black nor his white peers accepted him. He eventually found comradery in gang life, committed robberies and stole cars. Childhood abuse, three stabbings and a car accident left him with anxiety and post-traumatic stress disorder, he said.

Now 35, Ware has been drug-free for more than a year on the Oregon Coast, and he’s looking to the future. He believes meth didn’t cause him to become delusional because he kept himself fed, rested and hydrated. When he acted out of character, he said his “homeboys” would tell him to “get his ass to sleep.”

And, he was housed.

He has friends who were not as lucky. He said a few have lost their minds to meth. “It’s like talking to a brick wall,” he said.

Meth strains state psychiatric hospital

The mental health impacts of meth and homelessness are apparent at Oregon State Hospital, which has 546 psychiatric beds between its hospitals in Salem and Junction City.

Last year, the per-patient daily cost of care there was $1,447, with Oregon taxpayers footing most of the bill. The state health authority director, Pat Allen, has called it the “world’s most expensive homeless shelter.”

It’s where people facing criminal charges who are found mentally unfit are often recommended for admission. Staff at the hospital say the growing number of these patients who are homeless and use meth are taking longer to treat due to increasingly severe illness.

“Folks are coming through the door more acutely, psychiatrically ill, more psychotic — a little bit harder to stabilize,” said Sara Walker, the psychiatric hospital’s chief medical officer, adding that it’s hard to tell how much of the trend is meth, and how much of it is societal problems such as homelessness.

Walker said that patients being restored for prosecution are typically at the hospital for about 90 days, which is not long enough to make a definitive mental health diagnosis for someone who has been using meth. It’s unclear if or when their symptoms will resolve, or “clear.”

“There are plenty of folks who do not become psychotic until they graduate to methamphetamine use … And sometimes they clear, and sometimes they don’t,” Walker said. “You’re typically not going to know just how clear somebody’s going to get unless they are sober for a solid two years — which is not an easy thing to accomplish.”

A couple of years ago, an intern at the Oregon Health Authority researched drug use among the patients sent to Oregon State Hospital because they were mentally unfit for prosecution. From the start of 2017 to the end of 2018, the intern found that 96% had a history of substance abuse, with nearly 70% having used meth.

Walker doesn’t think those percentages have changed. What has changed is the number of these patients admitted to the hospital. Fifteen years ago, people being treated for court competency comprised about 15% of the daily population. Today they comprise about 60%, according to Walker.

But while their stays at the hospital tend to be shorter, their share of admissions is even greater. Last year they accounted for 94% of all patients admitted to Oregon State Hospital, according to hospital spokesperson Amber Shoebridge.

Hospitals trapped in ‘really bad cycle’

The surge of patients facing criminal charges means there are not enough beds in the state facility for patients who aren’t.

In December 2019, Oregon State Hospital management let hospitals know it would no longer accept civilly committed patients. These are people who are found to be a danger to themselves or others due to acute mental illness.

This forced other hospitals to board patients they would typically transfer to the state for long-term care. And the state’s largest hospital system has become backed up with psychiatric patients it has nowhere to send, according to Robin Henderson, Providence Oregon’s chief of behavioral health.

“We recently had an individual with us for 694 days,” Henderson said, adding that hospitals can’t offer the long-term therapies these patients need. “We don’t have an outside area for somebody to be able to go to — so this individual’s feet didn’t touch grass.”

Patients occupying beds long-term means the hospital must turn other people away.

“It’s a simple math problem,” Henderson said. “It really just kind of backs up the whole system.”

For Henderson, meth’s role in crowding at the Oregon State Hospital — and the “unintended consequences” for hospitals — is clear. “It’s a really bad cycle we’re in right now,” she said.

The problem has gotten so bad that hospitals and the Unity Center for Behavioral Health have begun going to court to force the state to take these patients off their hands.

Boarding psychiatric patients is adding to the strain on hospitals’ finances — which in turn affects their ability to fill staffing gaps. At the Unity Center in Portland, boarding civilly committed patients is hampering its ability to serve its purpose: to serve as a space for people suffering acute mental health crises.

Meanwhile, hospitals are also overtaxed with the influx of shorter-term emergency room visits related to meth. There were nearly 7,500 such visits to Portland area emergency departments last year, eclipsing the number of alcohol-related visits. At their worst, these meth-involved visits can include patients acting violently and erratically, resulting in injuries to the patient and staff.

Untreated addiction feeds a revolving door

Despite widespread substance use among patients facing criminal charges at Oregon State Hospital, addiction treatment is typically not an option.

Patients’ condition must be somewhat stabilized before they can fully engage in substance use treatment. But to keep patients in the hospital longer than it takes to restore their competency to stand trial would infringe on their civil rights, said Julia Howe, Oregon State Hospital’s chief of psychology.

In March 2020, an Oregon State Hospital work group began to develop recommendations for improving substance use treatment for patients. But, a spokesperson said, the pandemic put that work on pause.

In June, an outside expert recommended the expansion of substance use disorder treatment at the hospital, suggesting criminally involved patients would be less likely to reoffend.

The lack of treatment feeds a revolving door in which patients are restored to face trial, get released, go back to meth and homelessness, and then end up at the state hospital again, only this time more acutely psychotic and challenging to treat, according to state hospital staff.

Workers at other hospitals around the state see the same thing — people returning again and again due to meth use. And it takes an emotional toll.

“Every time you see the person again, they’re worse than they were the last time you saw them. And they’re less the person that they were,” Henderson said. “It’s very sad, and it’s a very helpless feeling. And I think helplessness is probably the hardest thing that emergency department staff deal with.”

Correction: This story has been updated to reflect that homelessness has increased nearly 40% in Multnomah County between 2015 and 2022.

This story about meth’s impact on behavioral health was produced by The Lund Report, an independent nonprofit health news organization based in Oregon. The Lund Report is tracking addiction issues as part of a reporting fellowship sponsored by the Association of Health Care Journalists and The Commonwealth Fund. Emily Green can be reached at emily@thelundreport.org.